More on COPD documentation and coding challenges

Part 2 of 2

Chronic obstructive pulmonary disease (COPD) is one of the most frequent reasons for
inpatient admission, and the nuances of the diagnosis, documentation, and coding of
the disorder and related conditions are numerous. Last month's column dealt with recognition
and diagnosis. This month's focuses on how to accurately reflect the severity of illness
of patients with COPD, which can have a substantial impact on quality metrics and
revenue.

Photo by Thinkstock.

First, the acuity of COPD must be specified: Always document whether or not there
is an acute exacerbation or decompensation. It doesn't matter that there may be only
a mild exacerbation; any acute change of mild degree is still significant. An acute
exacerbation is recognized by worsening of symptoms, like shortness of breath and
cough, associated with findings such as tachypnea and wheezing. It is commonly precipitated
by another condition like acute bronchitis, pneumonia, or heart failure. A point to
remember is that Medicare's diagnosis-related group (DRG) system assigns the same
degree of severity to a diagnosis of COPD with documentation of “acute bronchitis”
as to an acute exacerbation of COPD.

Assessing severity also includes consideration of the possibility of coexisting chronic
respiratory failure, which is characterized by variable degrees of hypoxemia and/or
an elevated partial pressure of carbon dioxide (PaCO2). Keep in mind that any patient requiring continuous supplemental home oxygen has
significant chronic hypoxemic respiratory failure, which should be documented. Many
other patients have chronic hypercapnic respiratory failure with hypoxemia not severe
enough to warrant home oxygen; these patients also need to be specifically identified
as having chronic respiratory failure. Some patients will have a combination of chronic
hypoxemic and hypercapnic respiratory failure.

Acute respiratory failure (with or without preexisting chronic respiratory failure)
is very commonly associated with acute exacerbations of COPD and related conditions
or complications. Some clinicians prefer to describe patients with preexisting chronic
respiratory failure as having “decompensated” or “exacerbated”
rather than “acute” respiratory failure, especially when mild, and this
is perfectly acceptable for coding purposes. Acute respiratory failure is also classified
as hypoxemic, hypercapnic, or both.

Acute hypoxemic respiratory failure is defined as a partial pressure of oxygen (PaO2) less than 60 mm Hg, which is equivalent to oxygen saturation (SaO2) of 91% on room air, or a PaO2/FiO2 ratio less than 300 (where FiO2 is the fraction of inspired oxygen expressed as a decimal). For patients who require
home oxygen, these criteria cannot be used, but a PaO2 less than 60 mm Hg (SaO2 <91%), measured not on room air but on the patient's usual home oxygen flow rate
or higher, is a valid indicator of an acute decompensation of chronic respiratory
failure.

Acute hypercapnic respiratory failure is identified by a PaCO2 greater than 50 mm Hg and a pH less than 7.35. This is sometimes described as respiratory
acidosis, but this term does not properly describe the severity of illness associated
with acute respiratory failure. The low pH indicates there has been an acute retention
of carbon dioxide (converted to carbonic acid in solution). A normal pH with elevated
PaCO2 indicates that respiratory failure is chronic (not acute) due to neutralization of
carbonic acid by the renal compensatory increase in bicarbonate that occurs with baseline
stable chronic respiratory failure.

Right now there is no ICD-10-CM code for acute cor pulmonale due to COPD or any other
condition except pulmonary embolism. It is hoped that this situation will soon be
remedied, and if it is, recognizing and documenting an acute decompensation of chronic
cor pulmonale due to COPD or another condition will become very important. An astute
clinician can often recognize acute cor pulmonale based on physical examination and
clinical circumstances without having to order a Doppler echocardiogram.

Commonly, patients with COPD and chronic heart failure present with symptoms that
may be due to either or often both. Heart failure should always be clarified in the
record as systolic or diastolic based on ejection fraction (EF): Systolic heart failure
is denoted by an EF below 55%, while diastolic is denoted by an EF equal to or greater
than 55%. If there is any evidence of decompensated heart failure, even if only mild,
it should also be clearly described as an acute exacerbation or decompensation to
accurately represent its severity. Some indicators of decompensation include: a B-type
natriuretic peptide (BNP) level greater than 500 pg/ml, an NT-pro-BNP level greater
than 3,500 ng/ml, new or increasing pleural effusion, new or increasing pretibial
edema, or bilateral fine wet rales.

The code assignment currently required by ICD-10-CM in cases of pneumonia with COPD
(whether acutely exacerbated or not) makes little clinical sense. ICD-10-CM contains
a code titled “COPD with acute lower respiratory infection” (code J44.0),
and coding guidelines indicate that pneumonia is a lower respiratory tract infection.
However, the coding instructions require code J44.0 be sequenced before the pneumonia
code, making COPD the principal diagnosis even when the patient is admitted primarily
for pneumonia even with no acute exacerbation of COPD. This rule assumes that pneumonia
is always a manifestation of COPD. Even if the patient has culture-positive bacterial
pneumonia caused by, for example, Pseudomonas or Staphylococcus species, the principal diagnosis will be COPD and it will be assigned to a COPD DRG
instead of one for pneumonia.

Oddly, aspiration pneumonia is not classified by ICD-10-CM as an infection, unless
specifically documented as bacterial or viral, but rather as pneumonitis due to inhalation
of food and vomitus. Therefore, the code J44.0 instruction would not apply. It's crucial
to identify and document suspected aspiration in circumstances that suggest it.

In summary, many important documentation and coding considerations for COPD and its
related conditions have a substantial impact on severity classification, quality metrics,
and revenue: acute exacerbation or decompensation of COPD; chronic respiratory failure;
acute (or acute-on-chronic) respiratory failure; coexisting systolic or diastolic
heart failure, including both chronic and acute exacerbations or decompensation (even
if mild); and coexisting pneumonia, especially if aspiration is likely the cause.

Dr. Pinson is a certified coding specialist, author, educator, and cofounder of Pinson and Tang, LLC in Houston. This content is adapted with permission from Pinson and Tang, LLC.

Ask Dr. Pinson

Q: We are hoping you might be able to further expand on yourCoding Corner columnfrom the November 2011ACP Hospitalist,“Whose documentation counts?”

There are conflicting viewpoints within our clinical documentation improvement/coding
departments regarding coding from medical student documentation. The information we
have been able to find is related to physician billing; we are unable to locate clear,
definitive advice involving hospital-based billing. Although CMS's Official Guidelines
for Coding and Reporting define a provider as “any qualified healthcare professional
who is legally accountable for establishing a diagnosis,” our conflicting opinions
revolve around the fact that student notes are cosigned by a qualified health care
professional, i.e., the attending physician.

Can you provide definitions of cosign and attestation as they pertain to medical student
notes? Does the presence of a cosigner who is a qualified provider enable us to code
from student notes? If so, if a physician erroneously cosigns a nurse or therapist's
note that contains diagnoses, do these notes then become codeable as well? Does the
attending need to restate medical student diagnoses in a separate note or attestation
in order to code them? Are medical student notes part of the permanent record if they
are cosigned? If not, should notes that do not remain in the permanent record be used
to generate codes?

A: As you noted, coding can be based on any “provider” as defined by CMS.
Providers must be licensed by their state to evaluate and treat patients and must
be credentialed by their hospital. Obviously, medical students don't qualify.

When an attending countersigns a medical student's documentation, she is acknowledging
that she has reviewed it. Unless she writes a separate “attestation”
making pertinent comments and confirming the diagnoses, the student's documentation
cannot be used for coding and no claims can be submitted based on it. Documentation
by residents at any level, if they are licensed and credentialed, can be used for
coding without an attending acknowledgment. Attendings regularly “attest”
to residents' notes because it is a requirement if the attending intends to submit
a claim based on those notes.

For any health care professional who does not meet the CMS definition of provider,
code assignment would follow the same rules as for medical students. All notes written
by health care professionals, including medical students, are part of the legal health
care record. Physicians should be aware that when they countersign or attest to someone
else's documentation they can be held accountable for it.

Q: Our surgical staff find the CMS requirement for documentation of the word “excisional”
whenever they perform surgical debridement frustrating, as any time they debride any
tissue it is always excisional. They believe CMS should just assume excisional debridement
and they asked me if there is any society that can help advocate for this change from
CMS. Would you happen to know of any forums that I may turn to to advocate for such
a change?

A: Thanks for contacting me about this. For submission of code changes, visit the CDC website. However, I think an organization or institution may have to submit requests. I know
there is no physician representation on this committee. It is essentially a certainty
that CMS will not change this requirement. However, if the surgeon uses the term “excised”
or “excisional” anywhere in the procedure note or medical record, the
procedure should be coded as an excisional debridement. Make sure your hospital coding
professionals are clear on this point.

Got a documentation or coding conundrum? Dr. Pinson answers questions from readers
quickly, and some may be published. Please email your question.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.